Cataract surgery without anaesthesia: two descriptions
by Arthur Jacob.

Abstract:

Dr Arthur Jacob (1790-1874), of Dublin, Ireland, was one of the
leading ophthalmologists of his time. He was the first to describe the
membrane that contains the rods and cones in the eye (membrana Jacobi)
and basal cell carcinoma (Jacob's ulcer). He made a curved needle
for cataract surgery from a sewing needle (Jacob's needle). Two
descriptions of cataract surgery without anaesthesia are presented.

Cataract surgery is now usually performed with the aid of one of
several techniques of local anaesthesia. The cornea and conjunctiva are
well innervated and in modern societies there is usually an expectation
that there will be minimal or no pain during procedures on the eye.

Cataracts were treated in the early 19th century by extraction
through an incision in the cornea, inferior displacement of the lens
with a needle (depression or couching) or by fragmentation of the lens
using a needle. For the latter procedure, the needle was introduced
either through the cornea, anterior to the iris (keratonyxis) or through
the "sclerotic" (sclera), posterior to the iris
(scleroticonyxis).

This article provides a brief biography of Dr Arthur Jacob, one of
the leading ophthalmologists of his time, a description by him of the
making of his needle for cataract surgery and extracts from two
descriptions of cataract surgery without anaesthesia. The two
descriptions are unusual as they also include the patient's
responses to the procedures and provide a vivid and chilling account of
surgery in the first half of the 19th century. The descriptions, from
the late 1830s and 1850, are within a few years of the introduction of
ether anaesthesia and several decades before the development of measures
for infection control. No indication of the success rates and rates of
complications of ocular surgical procedures were found. Surgical
procedures were then not commonly performed and the mortality from major
procedures was high.

ARTHUR JACOB

Arthur Jacob (1790-1874) (Figure 1) was born in Knockfin, a
townland near Maryborough (now Portlaoise), in Queens County (now County
Laois), ireland (1,2). Both his father and grandfather were surgeons. He
was apprenticed to his father in 1808 and studied medicine under Abraham
Colles at Steevens's Hospital, Dublin. He received his M.D. from
Edinburgh in 1814. He also attended lectures and studied in Paris and
London. in London, he studied under Sir Benjamin Brodie, Sir Astley
Cooper and Sir William Lawrence.

[FIGURE 1 OMITTED]

On his return to Dublin in 1819, he was appointed as Demonstrator
of Anatomy in the School of Trinity College. He was one of the founders
of the Park Street School of Medicine in 1824. In 1827, he became
Professor of Anatomy and Physiology at the Royal College of Surgeons in
ireland, and held the post until 1867 (3). in 1832, he was one of the
College Professors who founded the City of Dublin Hospital. He was twice
elected President of the Royal College of Surgeons in ireland (in 1837
and 1864).

Arthur Jacob and Henry Maunsell founded The Dublin Medical Press in
1839, with Arthur Jacob as its first editor from 1839 to 1859. He was
known for his "robust" language and personal attacks on
medical colleagues1. The following quotation, from p. 604 of an article
on Arthur Jacob by Somerville-Large (1), contains examples of the
language used at that time in medical journals: "He assails a
professorial rival with 'the chronic medico-literary diarrhoea
under which the learned Professor has so long laboured', 'the
heterogeneous discharges with which he inundates the journals',
'the foetid ichor which distills from such a quill'. The
editor of The Lancet (1841) is no less outspoken. 'Messrs. Jacob,
Maunsell, Porter, all the rag, tag and bobtail of the College School,
hatched in corruption, though they still linger about the dunghill that
gave them birth' " (1).

Arthur Jacob is especially known for his work in ophthalmology. in
1816, he discovered a membrane of the retina, the membrana Jacobi, now
known to consist of rods and cones. His description of this new layer
was published in 1819 (4). He is credited with reviving cataract surgery
through the cornea with a curved needle which he had invented. This
curved needle, called Jacob's needle, was first described in 1827
(5). He was the first to describe basal cell carcinoma, also known as
rodent ulcer or Jacob's ulcer (6). His book, A treatise on the
inflammations of the eyeball, is regarded as one of the classics in
ophthalmology (7). Another aspect of Arthur Jacob's career was the
animosity between him and William Wilde (father of Oscar Wilde), his
"brilliant young contemporary" (1).

Arthur Jacob's second son, Samuel, became an oculist in
Melbourne, Victoria. His fourth son, Archibald Hamilton, succeeded him
as an oculist in Dublin and editor of The Dublin Medical Press (1).

Detailed accounts of his career (with some inconsistency in dates)
can be found in two articles in the British Journal of Ophthalmology
(1,2).

JACOB'S NEEDLE

in 1827, Arthur Jacob described how he made and used a curved
needle for cataract surgery (5). The curved needle was made by bending
an ordinary sewing needle at one end. The other end was inserted into a
cedar handle. Cedar was used because it was light in weight.

"I determined to try a fine sewing needle curved at the point,
and after about forty operations i do not feel in the least inclined to
repent of my choice. i am on the contrary every day more and more
satisfied that it affords peculiar and unquestionable advantages. it
rarely, if ever, leaves even the slightest mark in the cornea ... There
is one difficulty attending the use of the round needle; it requires
very considerable force to pass it through the cornea; so much indeed as
frequently to embarrass those who use it for the first time ... The
greatest advantage in the use of the needle results from the very
circumstance which causes the difficulty in its introduction, it is from
its conical form firmly wedged in the cornea, prevents the aqueous
humour from escaping, and in consequence of being thus fixed, gives the
surgeon a power of holding the eye that defies every effort on the part
of an unruly patient, unless he actually pluck out the instrument with
his hand. if the head be suddenly drawn back the surgeon has only to let
the instrument rest loosely on his hand, and follow the motions of the
patient. i have seen the needle under such circumstances slip from the
hand of the surgeon, and hang from the eye without serious mischief, the
handle being very light" (5).

"The size of the needle is known in the shops as number seven,
being the forty-fourth part of an inch in diameter, about one half the
size of the finest Saunders's needle which is made ... The point
can be turned to the requisite curve by means of a pair of cutting
forceps, or the ward of a small key; of course without heat, which would
destroy the temper. it must not however be expected that all needles are
so soft as to be bent thus cold: there may not be ten in a hundred of
this temper, but when once turned they retain the curve without any
danger of bending or breaking, and certainly possess a degree of
strength and temper never observed in needles separately forged and
finished by the best cutlers. They should always be tried before use by
passing them repeatedly through thick calves-skin leather. After they
have received the requisite curve, the point should be cut flat on each
side, on a fine hone, and carefully examined with a magnifying glass to
ascertain that it is perfect. The extent to which the point should be
curved may be left to the choice of the surgeon, reminding him that the
greater the curve the more effectual the needle will be when introduced,
but the difficulty of introducing it through the cornea will also be
greater. I therefore recommend those who use it for the first time to
choose one slightly curved. After the point has been turned, the needle,
held in the jaws of a pair of pliers or a vice, is to be run down into a
cedar handle, without cement, leaving only half an inch of blade, which
i have found to answer every purpose" (5).

ARTHUR JACOB'S DESCRIPTION OF CATARACT SuRGERy

Arthur Jacob felt that using a needle through the cornea
(keratonyxis) was the most easily performed operation for cataract and
least traumatic to the eye. The disadvantages were that the procedure
may need to be repeated and the improvement in the patient's vision
was slower than that following the other operations for cataract.

The following extract from a description of cataract surgery is
from pages 21 and 22 of Jacob's book, The Removal of Cataract as
Performed with a Fine Sewing Needle through the Cornea8. The part of the
surgical procedure that has the patient's response has been quoted.
The pupil was usually dilated preoperatively using belladonna.

"I seat the patient in a chair and make him sit straight up or
inclining, according to his height. if very tall I raise myself by
standing on a large book or two, or on anything which answers the
purpose to be found at hand. in my own place of business I find old
medical folios answer the purpose well: operating chairs, although very
imposing and calculated to produce effect, I have not adopted; not
finding myself at ease with such things. When he is seated I lay the
patient's head against my chest, and placing the middle finger of
my left hand on his lower and the forefinger on his upper eyelid, and
gently holding the eye between them, I strike the point of the needle
suddenly into the cornea, about a line from its margin, and there hold
it until any struggles of the patient, which may be made, cease. There
must be no hesitation here, for if the cornea be touched without fixing
the point of the needle in it, the eye will turn rapidly and the surface
will be scratched. I advise the operator to pause here for a moment,
holding the eye firmly and steadily on the point of his needle, and if
necessary to say a word of encouragement or remonstrance to the patient.
After quietness becomes restored, the needle is to be pushed on with a
firm hand through the cornea into the anterior chamber, directing its
point downward and backward to the centre of the surface of the lens.
This is the most difficult step in the operation, and that part of it
which requires most confidence in the instrument. If the surgeon now
hesitates from the feel of resistance experienced he will not succeed.
He must push on, fearless of consequences, until the needle passes
through: in doing so, however, the eye will often turn from him or yield
before the pressure, even until the pupil, iris, and the cornea itself
are hidden under the eyelid; still he must push on until he is satisfied
that the needle has fairly entered the anterior chamber, when he relaxes
the pressure and allows the eye to recover its natural position. Here,
again, he had better pause a moment to allow the patient to recover his
composure, which is often disturbed in this the roughest step of the
operation, and also to ascertain the distance to which the needle has
passed, and how the point lies as to the margin of the pupil" (8).

WILLIAM GUYBON ATHERSTONE'S LECTURE NOTES

in 1996, while researching early ether anaesthesia in South Africa,
the author came across a notebook of William Guybon Atherstone (1814 to
1898) of lectures he had attended in Dublin in the late 1830s. The
notebook (accession number KCM 97/22/4) was archived at the Killie
Campbell Africana Library (now called Campbell Collections), University
of KwaZulu-Natal, Durban, South Africa. One of the lectures, "Dr
Arthur Jacob on Diseases of the Eye", contained a description of
cataract surgery and several sketches of ocular incisions and
instruments. One of the sketches was of Dr Jacob's curved needle
for keratonyxis (Figure 2).

William Guybon Atherstone was initially apprenticed to his father,
John Atherstone, a doctor in Grahamstown, South Africa. He then studied
Medicine in Dublin and returned to Grahamstown in 1839. He was also a
keen naturalist, geologist, founder of the Albany Museum in Grahamstown
and, later in his life, a Member of the Cape Parliament. His two main
claims to fame are his role in the identification of the first diamond
found in the Kimberley district of South Africa and the first
administration of ether for a major surgical procedure (an above knee
amputation performed on 16 June, 1847) in South Africa (9).

[FIGURE 1 OMITTED]

Extracts from the notes made by William Guybon Atherstone of a
lecture by Arthur Jacob

The extracts below are from pages 14 to 17 of Atherstone's
notes of the lecture by Arthur Jacob. The original spelling has been
retained. The discussion of Jacob's needle is followed by a note on
the use of a needle to break up a cataract. An operation to extract a
cataract and instructions for postoperative care are then described.

"Jacob's needle for keratonyxis (cedar handle)"
(Figure 2).

"The great difficulty in using it is the force it requires to
send it thro' the cornea. but it repays you when you get it in for
no aqueous humour can escape and let them roll their eyes how they like
it will not slip out. he has even let it alone hanging from the eye, but
generally in this dilemma it is best just to support the handle. He
therefore makes the handle of cedar for lightness. Opthalmostats are
instruments for fixing the eye in operation, Dr J. does not like them.
if you once begin to use them you can never do without them. The hand is
the best instrument, your finger the best opthalmostat."

"Tuesday Apr. 11. Dr J. performed the operation of breaking up
the lens on a soft cataract. The pupil previously irregular became
regular directly that adhesions were broken thro'. He waited some
time after the first thrust before beginning to break it up. never stop
an operation from any contingency or effort of the patient. finish when
once you have begun sooner than risk a 2nd operation pending inflamm.
even if the iris was transfixed by the needle draw it back and push it
into the pupil."

"Operation of Extraction. only desirable in hard cataract but
even in this it is often very difficult in small sunken eyes. The great
objection to it is its much greater complexity, difficulty, risk of
after ill effects ... learn how much the patient will wince by first
applying a blunt instrument."

"1st Step. cut the cornea thus (Figure 3). flap the bottom
part near the junction with the sclerotic ... the difficulty in making
this cut is from the wincing of the patient, and his rolling his eye
inwards. The humour always escapes and there is an obvious danger from
prolapse of the iris. it falls under the blade of the knife it is very
difficult to obviate this. if you withdraw the knife it is a spoiled
operation and a lost eye most certainly, and therefore Dr Jacob says
'never mind it, cut away, iris and all, it escapes with a slight
nick and it is the least of the two bad things'."

[FIGURE 2 OMITTED]

"2nd Step. Having made the cut calm the patient and let him
lie still & quiet a few minutes; then tear open the capsule of the
lens with any needle (as Scarpas'). then let the patient lie still
again for a while. the lens often comes out of itself but a little
manipulation is generally necessary. if much vitreous humour escapes the
lens often falls back and you can't get it out at all. a little
bistoury or scimitar blade is often requisite to enlarge the opening of
the cornea. The curette is a small curved scoop to get at the lens where
it is difficult to remove."

"Treatment after the operation. Don't put a full hot
bandage round the head, but a nice little linnen pad on it. keep it wet
with cold water. you must have the constant attendance of a good nurse,
it is requisite to the cure. many a good operation is spoiled for want
of a good nurse. The patient should be kept in the dark, and quiet.
check all cough and nausea. the efforts are very bad in their effects.
be very cautious for the first 3 or 4 days of touching the eye for fear
of interfering with the healing process or interrupting it.
antiphlogistics to be used when necessary."

CONCLUSiON

Arthur Jacob was a highly respected figure in medicine in Dublin.
He revived cataract surgery through the cornea with a curved needle
which he had invented (Jacob's needle). He was the first to
describe the membrane consisting of rods and cones (membrana Jacobi) and
also the first to describe basal cell carcinoma (rodent ulcer,
Jacob's ulcer). His vivid descriptions of cataract surgery
performed less than two hundred years ago, without any anaesthesia, are
a reminder of the rapid progress that has been achieved in medicine and
the changes that have occurred in the expectations of patients and
society.

ACKNOWLEDGEMENT

I would like to thank Emily-Ann Krige, Senior Archivist, Campbell
Collections, University of KwaZulu-Natal, Durban, South Africa for
assistance regarding William Guybon Atherstone's notebook. I would
also like to thank Mary O'Doherty, Assistant Librarian (Special
Collections and Archives), The Mercer Library, the Royal College of
Surgeons in ireland, Dublin, ireland.

(3.) O'Brien E, Crookshank A, Wolstenholme G. A Portrait of
Irish Medicine: An Illustrated History of Medicine in Ireland. Published
for the Bicentenary of the Royal College of Surgeons in ireland. Ward
River Press, Swords, Co. Dublin, ireland 1984; p. 79, 96.

(4.) Jacob A. An Account of a Membrane in the Eye, now first
described. Philosophical Transactions of the Royal Society of London
1819, 109:300-307.

(5.) Jacob A. On the form, construction and use of a cataract
needle, of a particular description, employed by Arthur Jacob, M.D. The
Dublin Hospital Reports and Communications in Medicine and Surgery 1827;
4:214-231.

(6.) Jacob A. Observations respecting an ulcer of peculiar
character, which attacks the eye-lids and other parts of the face. The
Dublin Hospital Reports and Communications in Medicine and Surgery 1827;
4:232-239.